Managing Severe GI Bleeding

Bad Bleeds
The Gut
Stuart Swadron, MD FRCPC FACEP

Associate Professor and Vice-Chair of Education Program Director, Residency in Emergency Medicine Los Angeles County-University of Southern California Medical Center
domingo 24 de junio de 12
Bad Bleeds
An Approach to Panic
Protecting Oneself!
Blood in the Basin
Localizing the Bleeding

THE BACK OF THROAT key to epistaxis
Localizing the Bleeding

HEMOPTYSIS HEMATEMESIS
Bright Red Frothy Alkaline

Dark Brown Food Coffee Grounds Acidic
The Chain of Survival
Severe Anything
The Chain of Survival

Endoscopist Interventional Radiologist Surgeon Hematologist
Emergency Physician
Massive Hemoptysis
WHERE ARE YOUR FRIENDS?

General Principles
vs.
AIRWAY AND BREATHING

General Principles

General Principles
Nonrebreather
Etomidate

General Principles
vs. Crystalloid Colloid
CIRCULATION
General Principles
Packed RBCs
Level One
CIRCULATION
General Principles
FFP
Platelets DDAVP
CIRCULATION
General Principles
PCC
Factor VIIa
CIRCULATION
General Principles
SIGNS FROM ABOVE

General Principles
A SIGN FROM ABOVE

Summary
SEVERE GI HEMORRHAGE
Intubate early Think IR and surgery right away
Massive GI Hemorrhage
How do I know if its massive?
How do I know if its massive? 1 You will feel it
How do I know if its massive? 1 You will feel it 2 There are pitfalls of the pulse
How do I know if its massive? 1 You will feel it 2 There are pitfalls of the pulse 3 If in doubt, assume its massive
How do I distinguish an upper from a lower GI bleed?
How do I distinguish an upper from a lower GI bleed? 1 You can be duped
How do I distinguish an upper from a lower GI bleed? 1 You can be duped 2 If in doubt, assume its upper
How do I distinguish an upper from a lower GI bleed? 1 You can be duped 2 If in doubt, assume its upper 3 Dont skimp on the NG tube
How do I distinguish variceal from nonvariceal hemorrhage?
How do I distinguish variceal from nonvariceal hemorrhage? 1 You can be duped
How do I distinguish variceal from nonvariceal hemorrhage? 1 You can be duped 2 If in doubt, assume its variceal
How do I distinguish variceal from nonvariceal hemorrhage? 1 You can be duped 2 If in doubt, assume its variceal 3 Dont skimp on the NG tube
Summary
Intubate early Think IR and surgery right away Assume upper Assume variceal
What drug should I hang?
What drug should I hang? Octreotide
50 g Bolus followed by 50 g/ Infusion
VERY SAFE
If the bleeding stops am I done?
If the bleeding stops am I done? Endoscopy is still needed urgently No clear criteria
Emergent Endoscopy
Recent Literature
Yan BM, Lee SS Gastroenterology
May 2003 EMERGENCY MANAGEMENT OF BLEEDING VARICES: DRUGS, BANDS OR SLEEP?
Opinion Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding
Emergent Endoscopy
Recent Literature
Opinion This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning.
Emergent Endoscopy
Recent Literature
Opinion Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.
What else can I do?
What else can I do? Balloon tamponade if:
Bleeding not stopping Endoscopist overcome Patient transfer
MR. LINTON 1 balloon 3 ports

MR. MINNESOTA 2 balloons 4 ports
LINTON TUBE DEMONSTRATION
Summary
PRE-SCOPE
Intubate early Think IR and surgery right away Assume upper Assume variceal Use octreotide empirically Use balloon tamponade if bleeding persists
What about gastric varices?
What about gastric varices?
Gastric varices
Diffuse portal hypertensive gastropathy
MEDICAL MANAGEMENT EMERGENT TIPS / SURGERY

Scope Findings: Esophageal Varices
Might have bled

Just bled!
Scope Findings: Peptic Ulcer Disease
Might have bled

Just bled!
What drugs should I initiate once I know the source?
What drugs should I initiate once I know the source?
VARICEAL NON-VARICEAL (Ulcer) NON-VARICEAL
Antibiotics
Proton Pump Inhibitors
What techniques are used endoscopically?
VARICEAL NON-VARICEAL (Ulcer) NON-VARICEAL
Banding
Injection + Coagulation
Is endoscopy ever contraindicated?
1 Surgical abdomen
1 Surgical abdomen 2 Ventricular tachycardia?
Massive Hematemesis
What is TIPS and who does it?
Massive Hematemesis
What is TIPS and who does it?
Massive Hematemesis
TIPS
Is there any role for the surgeon?
Is there any role for the surgeon?
YES!
What if this turns out to be lower GI bleeding?
What if this turns out to be lower GI bleeding? 1 Still ok to chase upper source first
What if this turns out to be lower GI bleeding? 1 Still ok to chase upper source first 2 Most severe LOWER GI bleeds are: NEED Diverticular bleeding IR / SURGERY Angiodysplasia
Summary
PRE-SCOPE
Intubate early Think IR and surgery right away Assume upper Assume variceal Use octreotide empirically Use balloon tamponade if bleeding persists
POST-SCOPE
Add antibiotics for varices Add PPI infusion for PUD

Massive GI Bleed
Resuscitation
Intubate if airway not protected or major bleed. Consider intubation for any EGD. Oxygen for everyone.
2 large bore IV or central access Type and screen if very stable Type and cross for all others Immediate hemoglobin Order CBC, coags, chem 7 +/- NG tube Proton Pump Inhibitor IV Octreotide for varices Antibiotics in ESLD SBP < 90? NS bolus! Coagulopathic? FFP! Platelets! Anemic and hypotensive? O negative or matched PRBC!
GI consult and EGD
No source of bleeding found
Colonoscopy
Source found
EGD not available, too much blood or transport needed

Minnesota or Linton tube to tamponade Temporizing measure Intubation needed
Intervention via EGD +/- Interventional Radiology, Surgery

Managing Severe GI Bleeding

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Bad Bleeds

Stuart Swadron, MD FRCPC FACEP

Blood in the Basin

Localizing the Bleeding

Localizing the Bleeding

Bright Red Frothy Alkaline

Dark Brown Food Coffee Grounds Acidic

The Chain of Survival

The Chain of Survival

WHERE ARE YOUR FRIENDS?

AIRWAY AND BREATHING

AIRWAY AND BREATHING

AIRWAY AND BREATHING

vs. Crystalloid Colloid

SIGNS FROM ABOVE

A SIGN FROM ABOVE

MR. LINTON 1 balloon 3 ports

MR. MINNESOTA 2 balloons 4 ports

LINTON TUBE DEMONSTRATION

Diffuse portal hypertensive gastropathy

MEDICAL MANAGEMENT EMERGENT TIPS / SURGERY

Scope Findings: Esophageal Varices

Might have bled

Scope Findings: Peptic Ulcer Disease

Might have bled

Proton Pump Inhibitors

1 Surgical abdomen 2 Ventricular tachycardia?

Add antibiotics for varices Add PPI infusion for PUD

GI consult and EGD

No source of bleeding found

EGD not available, too much blood or transport needed

Intervention via EGD +/- Interventional Radiology, Surgery

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